1, 2, 3, 4, 8 Department of Gynaecology,
2, 6, 7 Department of Sexology and Gender Problems,
5 Department of Endocrinology, University Hospital of Ghent, Ghent, Belgium

Introduction:
Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking.

Aim:
To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS.

Methods:
Fifty transsexual women who had undergone SRS >/=6 months earlier were recruited.

Main Outcome Measures:
Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored.

Results:
Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals.

Conclusions:
Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

Keywords:
Gender Identity; Sexual Behavior; Transsexualism

1 Department of Developmental Psychology, Ghent University, Ghent, Belgium
2 Department of Urology, University Hospital Ghent, Ghent, Belgium
3, 4, 5 Department of Sexology and Gender Problems, University Hospital Ghent, Ghent, Belgium

In this explorative study, nine stable relationships between female-to-male transsexuals and their biologically female partners were compared to an equal number of “traditional” heterosexual couples. The aim was to investigate any differences between these two groups on three aspects: satisfaction about the partner relationship, sexual satisfaction, and partnership sex typing. Data do not show any significant differences in relational and sexual satisfaction between the transsexuals’ female partner and the women in the “traditional” couples. In contrast, the female-to-male transsexuals and their female partners were found to have adopted a more pronounced sex-typed partner relationship than the “traditional” couples.

Background:
In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy.

Methods:
A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure.

Results:
The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating.

Conclusions:
Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated.

1, 2, 6, 8 Department of Sexology and Gender Problems, Ghent University Hospital, Belgium
7, 8, 9 Department of Endocrinology, Ghent University Hospital Belgium
3 Department of Gynaecology, Ghent University Hospital, Belgium and
4, 5 Center of Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands

Objective:
An unknown proportion of transsexual women (defined as post-operative male-to-female transsexuals on oestrogen replacement) experience hypoactive sexual desire disorder (HSDD). It has been suggested that the absence of ovarian androgen production together with oestrogen treatment-related increase in sex hormone-binding globulin (SHBG) levels could be leading to HSDD, due to low levels of biologically available testosterone. This study wishes to document the HSDD prevalence among transsexual women and the possible association to androgen levels.

Design:
Cross-sectional study.

Methods:
Transsexual women (n=62) and a control group of ovulating women (n=30) participated in this study. Questionnaires measuring sexual desire (sexual desire inventory) and relationship and sexual satisfaction (Maudsley Marital Questionnaire) were completed. Serum levels of total testosterone, LH and SHBG were measured in blood samples obtained at random in transsexual women and in the early follicular phase in ovulating women.

Results:
The transsexual group had lower levels of total and calculated free testosterone (both P<0.001) than the ovulating women. HSDD was reported in 34 % of the transsexual and 23 % of the ovulating women (P=0.30). Both groups reported similar levels of sexual desire (P=0.97). For transsexual women, no significant correlation was found between sexual desire and total (P=0.64) or free testosterone (P=0.82). In ovulating women, these correlations were significant (P=0.006, resp. P=0.003).

Conclusions:
HSDD is reported in one-third of transsexual women. This prevalence is not substantially different from controls, despite markedly lower (free) testosterone levels, which argues against a major role of testosterone in this specific group.

1, 6, 7 Department of Urology, Ghent University Hospital, Ghent, Belgium
2, 3, 4 Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
5 Department of Sexology, Ghent University Hospital, Ghent, Belgium

Objectives:
To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency.

Methods:
Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction.

Results:
There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed.

Conclusions:
This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

• Introduction
• Controversies Surrounding Surgery
• Ethical and Legal Challenges
• Financial Aspects
• Surgeries for Gender Reassignment
• Conditions for Surgical Interventions
• Standards of Care of the Harry Benjamin International Gender Dysphoria Association

A comprehensive and important text for health care professionals

Gender variance is widely misunderstood, and few medical texts examine the social, legal, emotional, historical, biological, and economic issues involved. Principles of Transgender Medicine and Surgery provides medical and health care guidelines and comprehensive information on all aspects of treatment of gender diverse individuals. This one-of-a-kind resource examines a full range of relevant data important to health care professionals. Each chapter addresses a different aspect of care, written by an authority on that sub-specialty. This practical guide instructs both novices and experienced practitioners on the state-of-the-art treatments and knowledge.

Principles of Transgender Medicine and Surgery presents the foremost international specialists on the issues, offering their expert knowledge on the wide spectrum of issues encountered by gender diverse individuals. In this handy text, professionals of all types can get important information about various aspects of transgender health care. This essential text is extensively referenced, and includes numerous photos, tables, and figures to clearly illustrate information.

Topics in Principles of Transgender Medicine and Surgery include:

• etiology
• primary medical care
• evidence-based preventive care
• hormone treatment of adults and juvenile transsexual patients
• general principles of surgical therapy
• reassignment surgery
• mental health issues
• developmental stages of the coming out process
• reproduction issues
• fertility issues
• karyotyping and genetics
• intersex individuals
• gender identity disorders
• aging and the care of elderly transgender patients

Principles of Transgender Medicine and Surgery is an essential guide for health care professionals, educators, students, patients, and patients’ families.

Department of Plastic Surgery, University Hospital of Ghent, Ghent, Belgium. selvaggigennaro@yahoo.it

Learning Objectives:
After studying this article, the participant should be able to discuss:

1. The terminology related to male-to-female gender dysphoria.
2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria.
3. The surgical goals of sex reassignment surgery in male-to-female transsexualism.
4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.

Background:
Gender identity disorder (previously “transsexualism”) is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.

Methods:
The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.

Results:
Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.

Conclusions:
This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.